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Did you know?….®
Adenoma Detection Rate (ADR), is the most important quality indicator for the colonoscopy procedure. The Adenoma Detection Rate is defined as the percentage of patients where the doctor performing a screening colonoscopy finds an adenoma (a pre-cancerous polyp). The acceptable ADR for average risk patients has been defined as at least 25%. So, if a doctor performs 100 screening colonoscopies, he or she should find pre-cancerous adenomas in at least 25 of those patients. The reason that the ADR is so important, is that it basically determines our ability to prevent colon cancer, as it is believed that all colon cancers start off as an adenoma. Studies have shown that high Adenoma Detection Rates translate into decreased rates of colon cancer. So, the higher a doctor’s ADR, the lower the chance that those patients (who had their colonoscopies) are going to develop colon cancer in their lifetime. In fact, it is believed that for every 1% increase in a doctor’s ADR, there is a 3% decrease in the risk of colon cancer!

I am very proud to report that my Adenoma Detection Rate over the past 2 years has been calculated at 51.5%. These are purely screening exams, meaning no symptoms such as rectal bleeding, change in bowel habits, constipation, etc. (I performed roughly 2,000 colonoscopies total over this time period). Thank you to Jason Martin, RN for pulling the screening colonoscopy data from our software. And to Sharon Rusnak in laboratory for pulling the pathology data.

Be well!

Did you know?……

Celiac disease is a hereditary condition where the affected patient can not tolerate gluten, a protein in wheat, rye, and barley. Ingestion of gluten in these patients causes inflammation and irritation of the small intestine. This in turn can cause malabsorption and a variety of symptoms and problems.
Symptoms can include diarrhea, bloating, and weight loss. Problems can include anything from iron deficiency anemia to osteoporosis to seizures. Surprisingly, the vast majority of patients go undiagnosed. Patients may get diagnosed in childhood or adulthood. Reportedly, the condition is as common as 1 in 133 people. It can be diagnosed by one of two ways: by blood tests or by upper endoscopy with biopsies. The only treatment is a strict gluten free diet, which is easier said than done. If you think you may have Celiac, we can order the appropriate blood tests or set up an upper endoscopy with appropriate biopsies.

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Did you know?…
We don’t usually feel comfortable talking about constipation, however it is an enormously common issue for many people. At some point in our lives, most of us will have at least transient issues with constipation. For some people, constipation is a chronic problem, resulting in abdominal discomfort, bloating, and just overall feeling bad. Not to mention, straining during bowel movements, hard stools, and the feeling of incomplete evacuation. Constipation is such a common problem, hardly a day goes by that we don’t see a patient in the office for this very issue. Although everyone is different in terms of their bowel habits, we generally refer to constipation as having less than 3 bm’s per week.
We can separate constipation into acute vs chronic. Acute constipation, generally refers to constipation that is a new problem, is intermittent, and has been going on for less than 3 months. Medications are one of the most common causes of new onset constipation, especially narcotic pain meds. Another common cause of acute constipation is the use of NSAIDs (ibuprofen, Advil, Aleve, etc) for aches and pains. Other medications that commonly cause constipation are heart and blood pressure medications. Even changes in normal routine, such as a vacation, decreased water intake, and a decrease in exercise, can cause acute constipation.

There are several different ‘varieties’ of chronic constipation, having official diagnoses of: CIC, or Chronic Idiopathic Constipation; Chronic slow-transit constipation; and IBS-C, or Irritable Bowel Syndrome with Constipation. Some prescription constipation medications are approved for one type over another, but we commonly treat them all in many of the same ways.

We usually start treatment with recommending an increase in fiber intake, increasing water intake, and exercising. Often times this is not enough, in which case we proceed to the use of stool softeners and laxatives. There are several OTC stool softeners and laxatives on the market (Colace, Dulcolax, Senna products, Miralax). There are also several prescription constipation medications (Amitiza, Linzess, Trulance). You should see your doctor if you are routinely needing OTC constipation medications, especially if they are not working. You should also see your doctor if you have constipation in combination with rectal bleeding and/or weight loss.

Be well!

Did you know?….
The Proton Pump Inhibitors (PPI’s) are one of the most commonly prescribed medications, and are taken by millions of Americans. Examples include Nexium, Prilosec, Protonix, Dexilant, Prevacid, etc. They are both over the counter (usually at half the prescription dose) and prescription. They are used for heartburn symptoms, as well as for diagnoses such as GERD, Peptic Ulcer Disease, Barrett’s esophagus, and others.

Recently, there has been a lot of bad press regarding these medications and possible side effects from their use. Various reported side effects (adverse events) include bone fracture, dementia, kidney problems, increased risk of C. diff, increased risk of gastroenteritis (stomach flu), pneumonia, and low vitamin/mineral levels (magnesium, calcium, iron). What do we do then with this information?

This is potentially a very long discussion, however, the main ‘take-home’ points here are as follows. Almost ALL of these potential side effects have been shown as Associations only, and Not A Cause and Effect relationship. In other words, virtually none of these studies proved that PPI’s CAUSED any of these conditions, only that they had a possible ASSOCIATION with them. In fact, when other researchers looked more closely at these studies, they often found flaws with them and what we call ‘confounding factors’. For example, perhaps patients at increased risk for dementia also were more likely to have conditions that required a PPI. Make sense?

What do I tell my patients? Basically, if you need a PPI for a legitimate reason, they are still one of the safest medications out there. If you don’t need it, or if your symptoms can be effectively managed with a medication such as Pepcid or Zantac (this is another topic), it’s not a bad idea to try those medications instead (as far as we know, those medications don’t have these potential side effects). Some people have conditions that will require a long term PPI (Barrett’s esophagus, bad reflux esophagitis, bleeding ulcer while on blood thinners). In this case, keep taking your PPI unless your provider advises you not to take it for a legitimate reason. Hope that helps!

Be well!

Did you know?….

Regular use of aspirin has been shown in numerous studies to decrease the risk of colon cancer. It has also been shown to decrease the risk of colon polyps, which are believed to be precursors to colon cancer. The studies have looked at individuals of different age groups and over different periods of time.

What is the optimal dose of aspirin for cancer prevention? Well, that answer is still not entirely clear, although overall it does not appear to matter what the dose of aspirin. Baby aspirin (which is usually 81mg) or full dose (325mg) both appear to reduce the cancer risk. Some studies show that higher doses provide larger benefits in cancer risk reduction.

How long does one have to take aspirin for it to be effective in decreasing cancer risk? Most studies seem to indicate that aspirin needs to be taken for at least a few years to have an effect. It seems that the longer one takes it, the more benefit it has.

Although aspirin’s cancer risk reduction appears to be most consistent with colorectal cancer, it has also been shown in studies to potentially decrease the risk of other cancers such as lung, prostate, stomach, liver, and pancreatic cancer.

As with everything else, there is a caveat. Recent research suggests that people over age 70 may have the reverse effect with aspirin use and cancer, however more research is needed here.

Before starting a daily aspirin regimen, make sure you consult with your doctor. People at risk of bleeding may need to avoid taking aspirin.

Be well!

Did you know?….

Recently, the recommended age to start screening for colon cancer has been decreased from 50 to 45 years. The reason for this is that there has been an increasing number of younger patients diagnosed with colon polyps and colon cancer. So by starting screening at a younger age, the hope is that we can prevent more cancers from forming. There are several different screening tests for colorectal cancer, with the three most common being: colonoscopy, Cologuard (a stool DNA test), and FIT testing (Fecal Immunochemistry Test, which detects blood in the stool). Gastrointestinal societies favor colonoscopy above the others, as this is the only test that can both find AND remove colon polyps at the same time.

If you undergo a colonoscopy and there are no polyps,the interval for the next exam remains at 10 years. The reasoning behind this 10 year time frame, is that it is believed that it takes at least 10 years for a polyp to turn into a cancer.

If polyps are found during the exam, the interval for the next colonoscopy decreases to either 3, 5, or 7 years (rarely a repeat is recommended in 1 year for specific reasons). If someone has a family history of colon cancer (in a first degree relative), the interval after even a normal exam decreases to 5 years.

Be well and remember to get screened!

Did you know….?

Anemia is the term for a low ‘blood count’ or low hemoglobin. The normal range for adults is roughly 12-16 g/dL (men tend to have a slightly higher average hemoglobin than women). So, anyone with a hemoglobin less than 12 can be said to be anemic. The range of anemia can be quite large. I have seen patients with a hemoglobin less than 3! (while up and walking around)! As a Gastroenterologist, I often get consulted for patients with anemia, since losing blood through the GI tract is one way a person can become anemic. A common misconception, is that ALL patients with anemia must be losing blood somewhere. This is NOT always the case. Two other very common forms of anemia are: 1) Anemia as a result of chronic kidney disease (CKD), and 2) Anemia as a result of a chronic medical condition (diabetes, COPD, CHF). Those are topics for another discussion.

Anemia caused by blood loss from the GI tract, results in Iron Deficiency Anemia. When you lose blood (hemoglobin), you also lose iron. The causes of this are many, but common causes include acid reflux induced esophagitis, an ulcer in the stomach or small intestine, small blood vessels in the lining of the GI tract called AVM’s or angiodysplasia, and a cancer (especially in combination with unexplained weight loss). We often need to perform an upper endoscopy as well as a colonoscopy, to look for these possible causes of anemia. What to look for to see if you may be losing blood from your GI tract? Blood in your stool or black stool (called melena). If you see this, you should let your doctor or medical provider know right away. Fortunately, most causes of GI blood loss are readily treatable.

Be well!

Did you know?…..

Helicobacter pylori (H pylori) is a bacteria that can live in your stomach for years and years. It is one of the only bacteria that can survive the acid environment of your stomach. It is acquired the same way many bacteria are acquired, through unclean water sources and foods. It is actually believed to be acquired when you are a child! It then literally lives in your stomach your entire life and you may not know you even have it! Fortunately, most of the time it does not cause problems. However, it can cause a variety of symptoms, most commonly abdominal pain, nausea, bloating, and a burning sensation in your stomach. It is also a leading cause of stomach and intestine ULCERS. Very rarely, it can lead to stomach cancer (don’t freak out, this is rare!).
There are several ways to test for the infection: 1) a blood test for the antibody to the bacteria 2) a breath test 3) a stool test or 4) biopsies of your stomach lining taken during an upper endoscopy.
Treatment is a little different than most infections. It requires 2 different antibiotics, along with a stomach acid medication (Protonix, Prilosec, Nexium, etc) twice a day. All for 10-14 days.
Interesting little bug, huh?

Be well!

Crohn's disease

Did you know….?

Abdominal bloating is one of the most common conditions we see in the office. It often is multi-factorial in nature (has several possible causes). Constipation is a common contributing factor. Just like stool can build up when someone is constipated, air/gas can also build up, and cause bloating. Diet is also another common cause of bloating. Certain foods, especially dairy products, can cause bloating and gas. This would include milk, cheese, ice cream, and don’t forget chocolate. A large number of people have a degree of lactose/dairy intolerance and do not realize it. Excessive soda/pop intake can contribute to bloating as well. Other possible causes include IBS and celiac disease. Many patients respond to a trial of a special diet called a ‘Low FODMAP diet’. This is basically a diet that is low in certain foods that are hard to digest and that tend to cause bloating and cramping.

Be well!

Did you know?….

Fatty liver disease or NAFLD (Non Alcoholic Fatty Liver Disease) is a major health problem across the United States. There are two subtypes of fatty liver disease: NAFL (Non Alcoholic Fatty Liver) and NASH (Non Alcoholic Steato Hepatitis). Put simply, NAFL describes abnormal fat deposition in the liver, without associated inflammation or scarring. NASH describes fatty liver with associated liver inflammation and often some scarring, or fibrosis. NASH can even lead to cirrhosis in some patients. Since so many people have fatty liver and NASH, it is a major cause of cirrhosis in this country, right up there with alcohol abuse and hepatitis C.

Fatty liver disease is very common, and we see new patients with this condition on almost a daily basis. As the obesity epidemic grows in this country, so does fatty liver disease. Risk factors include the following: obesity, diabetes, high cholesterol, and excessive pop intake. In addition, an ingredient in numerous foods and condiments called High Fructose Corn Syrup, is strongly associated with the development of fatty liver. Since so many people in southern Ohio drink excess soda pop, the rates of fatty liver and NASH are extremely high in this area. I can almost guarantee that when I am seeing a patient with cirrhosis caused by NASH for the first time, they will have a history of years of excessive soda pop intake.

Treatment of fatty liver disease is weight loss through diet and exercise, control of blood sugars in diabetics, treatment of high cholesterol/triglycerides, avoidance of high fructose corn syrup, and stopping pop intake. Numerous medications have been tried for NAFLD, but most have mixed results at best. Drug companies are working as we speak on new medications for this very common problem.

Be well everyone, and do yourself a favor…..stop drinking all that soda pop! Coffee = good for the liver, Pop = bad for the liver

Did you know?….

Diverticulosis is a condition in which small pockets (diverticuli) form in the wall of the colon, or large intestine. The condition is more common as we age, and affects the majority of people in their 70’s and 80’s. However, we sometimes find diverticulosis in patients as young as their early 30’s. It most often occurs in the sigmoid colon, which would be located in the left lower abdomen. In the majority of patients, diverticulosis does NOT cause any symptoms. Classic symptoms, when they do occur, include crampy left lower abdominal pain and bloating. As it gets worse, diverticulosis (or ‘tics’ for short) can be associated with diarrhea and constipation. Two rare complications from diverticulosis are bleeding (diverticular bleed) and infection (diverticulitis). We do not know why some people have diverticulosis and others do not. Likewise, we are not sure why some people get diverticulitis and diverticular bleeding. Some studies show an association between NSAIDs (ibuprofen, aspirin), obesity, lack of exercise, and smoking. I personally believe genetic factors play a big role, as in most medical conditions.
Diverticular bleeding is usually acute (all of a sudden) and a lot of bleeding. Unlike classic hemorrhoidal bleeding, diverticular bleeding is bright to dark red, large volume, and associated with lower abdominal cramping. Fortunately, most of the time, it resolves on it’s own. However, most patients will seek medical treatment for these symptoms, and end up being admitted to the hospital. Often times, a colonoscopy is performed in hopes of finding and stopping the bleed, however most of the time, all we find is old or fresh blood, with no clear source. Sometimes we get lucky and can localize the diverticular bleed, at which time we can clip, band, or cauterize the spot.
Diverticulitis is when one of the diverticular pockets becomes infected.
Typical symptoms are lower (usually left lower) abdominal pain, nausea/vomiting, and fevers/chills. Sometimes bowel habit changes occur as well (usually constipation from the swelling in the area). Antibiotics are usually required in true cases of diverticulitis. There is NO good evidence to suggest that nuts, seeds, or popcorn cause diverticulitis or diverticular bleeding. I have found from experience, that this is so ingrained in some of my patients’ beliefs, that I let them do as they choose in terms of avoiding these foods. I simply provide them with the best available evidence. We do generally recommend a high fiber diet when someone has diverticulosis, although admittedly the data for this is not great either.

Be well!

Did you know?….
Dysphagia is the medical term for difficulty swallowing. There are several different causes, although the most common is GERD (acid reflux)-induced inflammation of the lower esophagus. When acid reflux from the stomach comes up into the lower esophagus repeatedly over time, it causes irritation and swelling, which can narrow the lumen (opening) of the lower esophagus.
Therefore, food can get caught or ‘hung-up’ in this area. The most common types of food to get caught are meats (steak, chicken, pork). Bread products also tend to get hung up. Less common causes of dysphagia include a motility disorder (problem with how the esophagus contracts), a fixed stricture or narrowing, or worst-case scenario a tumor (often associated with black stool and weight loss). Dysphagia should be differentiated from ‘globus sensation’, which is the feeling that something is always present in the back of the throat or neck. Globus is often associated with stress and anxiety.

You may be surprised to know that the most common reason that most Gastroenterologists have to rush to the hospital after-hours, is a food impaction in the esophagus. So, we take dysphagia seriously!

Be well!

Did You Know?….
GASTROPARESIS is the term for delayed stomach emptying (sometimes referred to as a ‘lazy stomach’). It is very common in patients with diabetes, but can occur even if you don’t have diabetes. Sometimes it even develops after a stomach flu (post-infectious gastroparesis). Gastroparesis tends to cause the following symptoms: bloating, nausea, vomiting, feeling full shortly after starting a meal, and upper abdominal pain.

The condition is diagnosed by obtaining a radiology test called a ‘gastric emptying scan’, where the patient eats an egg meal that contains an invisible contrast agent that shows up on imaging. The time it takes for the entire meal to exit the stomach is then measured by a Radiologist.

The basic treatment for Gastroparesis involves the following:
1) Small, frequent meals
2) Be careful with high fiber foods and high fat content foods, as these types of foods tend to sit in your stomach the longest (Cooking vegetables or putting them in a blender can be helpful).
3) Good control of blood sugars in diabetics is very important
4) Regular exercise

If medication is required, we usually start with Reglan (metaclopromide), taken orally as needed, or up to 4 times a day (before meals and at bedtime). Reglan often gets a bad rap for potential side effects, however I have used this medication successfully in hundreds of patients over the years.

If someone has an allergy or side effects to Reglan, the only two other medication options available are Erythromycin and Domperidone.

Erythromycin is actually an antibiotic, but can help stomach emptying as a secondary effect. Domperidone does not have the side effects of Reglan or Erythromycin. However, this medication is not readily available in the United States. It can only be obtained from compound pharmacies (pharmacies that can actually make the medication on site) in the U.S. or online pharmacies in Canada and Europe.

Now, some patients will still have symptoms despite trying all of the above medications. If all else fails, there are several interventions that can be tried. These include: 1) upper endoscopy with Botox injection into the bottom part of the stomach (pylorus), 2) a procedure where a doctor cuts the muscle of the lower stomach during an endoscopy (G-POEM, which stands for Gastric Per Oral Endoscopic Myotomy), and 3) a gastric pacemaker placement.

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